Menu

9. Shoulder and Elbow MCQs

Practice Set 183 of 197

This practice set contains high-yield board review questions covering key concepts in 9. Shoulder and Elbow. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 3641

Topic: 9. Shoulder and Elbow

An examiner asks about the 'superior glenohumeral ligament (SGHL)'. What is its primary role in shoulder stability?

. Resisting anterior translation in abduction and external rotation.
. Resisting posterior translation in flexion and internal rotation.
. Resisting inferior translation of the humeral head in adduction.
. Preventing superior migration of the humeral head.
. Providing static stability to the acromioclavicular joint.

Correct Answer & Explanation

. Resisting inferior translation of the humeral head in adduction.

Explanation

The superior glenohumeral ligament (SGHL) plays a primary role in resisting inferior translation of the humeral head in the adducted position and, along with the coracohumeral ligament, forms the 'rotator interval capsule' which limits inferior and posterior translation. The inferior glenohumeral ligament (IGHL) complex is the primary restraint to anterior translation in abduction and external rotation. The SGHL does not prevent superior migration in the context of rotator cuff deficiency, and it does not stabilize the AC joint.

Question 3642

Topic: Shoulder Arthroplasty & Arthritis

In the biomechanical design of a Grammont-style reverse total shoulder arthroplasty (RTSA), how is the center of rotation (COR) altered compared to a native anatomic shoulder?

. Medialized and distalized
. Medialized and proximalized
. Lateralized and distalized
. Lateralized and proximalized
. Remains unchanged but constrained

Correct Answer & Explanation

. Medialized and distalized

Explanation

The Grammont-style RTSA medializes and distalizes the center of rotation. Medialization increases the deltoid lever arm and decreases torque on the glenoid component, while distalization tensions the deltoid, improving its efficiency for forward elevation in the absence of a functional rotator cuff.

Question 3643

Topic: 9. Shoulder and Elbow

A 40-year-old woman falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. During surgical reconstruction, what is the most widely accepted sequence of repair to restore elbow stability?

. LCL repair, radial head fixation/replacement, coronoid fixation
. Radial head fixation/replacement, LCL repair, coronoid fixation
. Coronoid fixation, radial head fixation/replacement, LCL repair
. MCL repair, coronoid fixation, radial head fixation/replacement
. Radial head fixation/replacement, coronoid fixation, MCL repair

Correct Answer & Explanation

. Coronoid fixation, radial head fixation/replacement, LCL repair

Explanation

The standard surgical algorithm for a terrible triad injury of the elbow is to build from 'deep to superficial' or 'inside out'. This typically involves: 1) Fixation of the coronoid fracture, 2) Fixation or replacement of the radial head, and 3) Repair of the lateral collateral ligament (LCL) complex. The MCL is only repaired if the elbow remains unstable after these steps.

Question 3644

Topic: Elbow & Forearm

A patient with a history of recurrent elbow giving way describes a clicking sensation when pushing out of a chair. Examination reveals a positive lateral pivot-shift test. This condition is most directly caused by incompetence of which of the following structures?

. Radial collateral ligament
. Lateral ulnar collateral ligament (LUCL)
. Annular ligament
. Anterior bundle of the medial collateral ligament
. Accessory collateral ligament

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

The patient's presentation is classic for posterolateral rotatory instability (PLRI) of the elbow. The primary pathoanatomy of PLRI is a deficiency or avulsion of the lateral ulnar collateral ligament (LUCL), which normally acts as a crucial restraint against posterolateral subluxation of the radial head.

Question 3645

Topic: Shoulder Pathology

A 28-year-old male sustains blunt trauma to his right posterolateral neck and shoulder. He subsequently presents with medial winging of his scapula, which worsens when he pushes against a wall. Which nerve is most likely injured, and what is its segmental origin?

. Spinal accessory nerve; Cranial Nerve XI
. Long thoracic nerve; C5, C6, C7
. Dorsal scapular nerve; C5
. Suprascapular nerve; C5, C6
. Thoracodorsal nerve; C6, C7, C8

Correct Answer & Explanation

. Long thoracic nerve; C5, C6, C7

Explanation

Medial scapular winging is caused by paralysis of the serratus anterior muscle, which is innervated by the long thoracic nerve. The long thoracic nerve arises from the ventral rami of the C5, C6, and C7 nerve roots.

Question 3646

Topic: 9. Shoulder and Elbow

A 55-year-old diabetic woman presents with stage II 'freezing' adhesive capsulitis of the shoulder. Histological evaluation of the joint capsule in this condition typically reveals dense fibroblastic proliferation. Which specific anatomical structures are primarily contracted and thickened early in the pathogenesis of this disease?

. Posterior band of the inferior glenohumeral ligament (IGHL)
. Coracohumeral ligament (CHL) and superior glenohumeral ligament (SGHL)
. Middle glenohumeral ligament (MGHL) and subscapularis tendon
. Transverse humeral ligament and biceps anchor
. Acromioclavicular joint capsule

Correct Answer & Explanation

. Coracohumeral ligament (CHL) and superior glenohumeral ligament (SGHL)

Explanation

The primary site of pathology in early idiopathic adhesive capsulitis is the rotator interval, which contains the coracohumeral ligament (CHL) and the superior glenohumeral ligament (SGHL). Contracture of these structures, particularly the CHL, heavily restricts external rotation, which is the hallmark clinical finding in frozen shoulder.

Question 3647

Topic: Elbow & Forearm

In the surgical management of recalcitrant lateral epicondylitis (tennis elbow), debridement is primarily targeted at the macroscopic degenerative tissue (angiofibroblastic hyperplasia) found within the origin of which muscle?

. Extensor carpi radialis longus (ECRL)
. Extensor digitorum communis (EDC)
. Extensor carpi radialis brevis (ECRB)
. Brachioradialis
. Extensor carpi ulnaris (ECU)

Correct Answer & Explanation

. Extensor carpi radialis brevis (ECRB)

Explanation

Lateral epicondylitis is characterized by angiofibroblastic tendinosis primarily involving the origin of the extensor carpi radialis brevis (ECRB). During surgical release/debridement, the ECRB origin is located deep to the extensor digitorum communis (EDC) aponeurosis at the lateral epicondyle.

Question 3648

Topic: 9. Shoulder and Elbow

A 35-year-old male presents with elbow trauma after a fall. Computed tomography shows a fracture of the anteromedial facet of the coronoid process. What is the primary mechanism of injury, and what is the recommended surgical approach for fixation if required?

. Varus posteromedial rotatory instability; medial approach
. Valgus posterolateral rotatory instability; lateral approach
. Axial load with elbow hyperextension; posterior approach
. Direct trauma; anterior approach
. Varus posteromedial rotatory instability; lateral approach

Correct Answer & Explanation

. Varus posteromedial rotatory instability; medial approach

Explanation

Anteromedial facet fractures of the coronoid occur due to a varus posteromedial rotatory instability (VPMRI) mechanism. The lateral collateral ligament (LCL) is typically avulsed from the lateral epicondyle, and the anteromedial coronoid facet is sheared off. Fixation is usually required to restore stability, specifically via a medial-based approach (such as a flexor carpi ulnaris split or Hotchkiss over-the-top approach) combined with lateral LCL repair.

Question 3649

Topic: Shoulder Arthroplasty & Arthritis

To minimize the risk of inferior scapular notching in a reverse total shoulder arthroplasty (RTSA), the glenosphere baseplate should ideally be positioned with which of the following orientations?

. Superior translation and superior tilt
. Superior translation and inferior tilt
. Inferior translation and superior tilt
. Inferior translation and inferior tilt
. Central placement and neutral tilt

Correct Answer & Explanation

. Superior translation and inferior tilt

Explanation

Scapular notching is a well-documented complication of RTSA, caused by mechanical impingement of the humeral polyethylene insert against the inferior scapular neck during adduction. To minimize this, the glenosphere baseplate should be placed as inferiorly as possible on the glenoid, usually flush with or slightly overhanging the inferior rim, and with a neutral to slightly inferior tilt.

Question 3650

Topic: Elbow & Forearm

A 40-year-old female sustains a coronal shear fracture of the capitellum and lateral trochlea. CT scan reveals extensive posterior comminution of the lateral condyle. According to the Dubberley classification, what is the surgical implication of this posterior comminution?

. It necessitates a purely medial surgical approach
. It precludes the use of isolated anterior-to-posterior headless compression screws
. It indicates an obligate concurrent radial head fracture
. It is an absolute indication for total elbow arthroplasty
. It signifies an intact lateral ulnar collateral ligament

Correct Answer & Explanation

. It precludes the use of isolated anterior-to-posterior headless compression screws

Explanation

The Dubberley classification of capitellum fractures distinguishes between Type A (no posterior comminution) and Type B (posterior comminution). Type B fractures lack a stable posterior buttress. Therefore, anterior-to-posterior headless compression screws alone will fail due to lack of posterior support. These require a posterior buttress plate to prevent displacement.

Question 3651

Topic: 9. Shoulder and Elbow

A 12-year-old male baseball pitcher presents with medial elbow pain and decreased pitching velocity. Radiographs reveal widening of the medial epicondyle apophysis. The pathophysiology of this condition (Little League Elbow) is best characterized by which biomechanical pattern during the late cocking and early acceleration phases of throwing?

. Varus overload causing medial compression
. Valgus overload causing medial tension and lateral compression
. Axial loading causing uniform radiocapitellar tension
. Repetitive hyperextension causing posterior impingement
. Valgus overload causing medial compression and lateral tension

Correct Answer & Explanation

. Valgus overload causing medial tension and lateral compression

Explanation

The throwing motion places severe valgus stress on the elbow. In skeletally immature athletes, this valgus overload causes excessive tension forces on the medial elbow structures (leading to medial epicondyle apophysitis or avulsion) and excessive compression forces on the lateral elbow structures (which can lead to osteochondritis dissecans of the capitellum).

Question 3652

Topic: Elbow & Forearm

A 45-year-old male sustains a 'terrible triad' injury of the elbow (dislocation, radial head fracture, and coronoid fracture) requiring operative fixation. What is the classic, biomechanically recommended sequence of surgical reconstruction for this injury complex?

. LCL repair, radial head fixation, coronoid fixation
. Radial head fixation, coronoid fixation, LCL repair
. Coronoid fixation, radial head fixation/replacement, LCL repair
. MCL repair, LCL repair, radial head fixation
. Coronoid fixation, MCL repair, LCL repair

Correct Answer & Explanation

. Coronoid fixation, radial head fixation/replacement, LCL repair

Explanation

The standard surgical algorithm for a terrible triad injury involves an inside-out approach: 1) Fixation of the coronoid process (to restore the anterior buttress), 2) Fixation or replacement of the radial head (to restore the anterior and lateral column), and 3) Repair of the lateral collateral ligament (LCL) complex to the lateral epicondyle. The MCL is only repaired if gross instability remains after these steps.

Question 3653

Topic: 9. Shoulder and Elbow
A 50-year-old diabetic female presents with globally restricted active and passive shoulder range of motion. Arthroscopic evaluation reveals dense, mature collagenous adhesions in the rotator interval and a thickened coracohumeral ligament, but minimal active synovitis. This presentation is consistent with the 'frozen' stage of adhesive capsulitis. Which cytokine is most strongly associated with the profibrotic cascade in this condition?
. Interleukin-6 (IL-6)
. Tumor Necrosis Factor-alpha (TNF-a)
. Transforming Growth Factor-beta (TGF-b)
. Fibroblast Growth Factor (FGF)
. Vascular Endothelial Growth Factor (VEGF)

Correct Answer & Explanation

. Transforming Growth Factor-beta (TGF-b)

Explanation

Adhesive capsulitis is characterized by an initial inflammatory phase followed by a dense fibrotic phase. Transforming Growth Factor-beta (TGF-b) and Platelet-Derived Growth Factor (PDGF) are the primary profibrotic cytokines responsible for fibroblast proliferation and collagen deposition in the joint capsule and rotator interval, distinguishing the 'frozen' stage (Stage III) from the earlier, highly vascular 'freezing' stage (Stage II).

Question 3654

Topic: Elbow & Forearm

A 22-year-old collegiate baseball pitcher undergoes medial ulnar collateral ligament (MUCL) reconstruction using a palmaris longus autograft via the modified Jobe (figure-of-eight) technique. Postoperatively, what is the most frequently reported complication specific to this procedure?

. Graft rupture
. Radiocapitellar arthritis
. Ulnar neuropathy
. Heterotopic ossification
. Medial epicondyle nonunion

Correct Answer & Explanation

. Ulnar neuropathy

Explanation

Ulnar neuropathy is the most common complication following medial ulnar collateral ligament (MUCL) reconstruction (Tommy John surgery). It can occur due to traction, compression during exposure, or issues related to ulnar nerve transposition (if performed). While modern techniques (like the docking technique) have reduced this rate by minimizing nerve handling, it remains the leading complication.

Question 3655

Topic: 9. Shoulder and Elbow

During normal human shoulder elevation from 30 degrees to 150 degrees, normal kinematics dictate a coordinated movement between the glenohumeral joint and the scapulothoracic articulation. What is the generally accepted overall ratio of glenohumeral to scapulothoracic motion (scapulohumeral rhythm)?

. 1:1
. 1:2
. 2:1
. 3:1
. 4:1

Correct Answer & Explanation

. 2:1

Explanation

The classic 'scapulohumeral rhythm' described by Inman et al. dictates a 2:1 ratio of glenohumeral joint motion to scapulothoracic motion during active arm elevation. For every 3 degrees of total shoulder elevation, 2 degrees occur at the glenohumeral joint and 1 degree occurs at the scapulothoracic articulation.

Question 3656

Topic: 9. Shoulder and Elbow

A 68-year-old male with primary glenohumeral osteoarthritis is evaluated for shoulder arthroplasty. Axillary radiographs and CT imaging reveal a biconcave glenoid with 25 degrees of posterior retroversion and significant posterior subluxation of the humeral head (Walch B2 glenoid). What is the most reliable surgical option to prevent early component failure in this older patient?

. Anatomic total shoulder arthroplasty with eccentric reaming to neutral version
. Hemiarthroplasty with concentric glenoid reaming
. Arthroscopic debridement and biologic resurfacing
. Reverse total shoulder arthroplasty
. Anatomic total shoulder arthroplasty with standard pegged glenoid

Correct Answer & Explanation

. Reverse total shoulder arthroplasty

Explanation

Managing a severe Walch B2 glenoid (high retroversion >15-20 degrees and significant posterior subluxation) with a standard anatomic total shoulder arthroplasty (TSA) is fraught with high failure rates. Asymmetric reaming to correct 25 degrees of retroversion would remove too much subchondral bone, violating the glenoid vault. In an older patient, Reverse Total Shoulder Arthroplasty (RTSA) provides much more reliable stability, corrects the subluxation, and has excellent long-term survivorship compared to standard anatomic TSA in this setting.

Question 3657

Topic: Elbow & Forearm

A 35-year-old male presents with recurrent catching and clicking in his right elbow, particularly when pushing himself up from a seated position. Physical examination reveals apprehension with axial compression, supination, and valgus stress applied to the elbow during flexion. Which of the following structures is most likely deficient?

. Medial ulnar collateral ligament (MUCL)
. Lateral ulnar collateral ligament (LUCL)
. Annular ligament
. Anterior joint capsule
. Radial collateral ligament

Correct Answer & Explanation

. Lateral ulnar collateral ligament (LUCL)

Explanation

The clinical scenario and provocative maneuver (lateral pivot-shift test of the elbow) are classic for Posterolateral Rotatory Instability (PLRI). PLRI is the most common pattern of chronic elbow instability and is caused by an insufficiency of the lateral ulnar collateral ligament (LUCL). The LUCL serves as the primary restraint to posterolateral rotatory forces. It originates on the lateral epicondyle and inserts on the supinator crest of the ulna.

Question 3658

Topic: Elbow & Forearm

In the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid fracture), standard surgical principles dictate a specific sequence of repair. Which of the following represents the most widely accepted sequence of structural reconstruction?

. Lateral ulnar collateral ligament (LUCL) repair -> coronoid fixation -> radial head fixation/replacement
. Radial head fixation/replacement -> coronoid fixation -> LUCL repair
. Coronoid fixation -> radial head fixation/replacement -> LUCL repair
. LUCL repair -> radial head fixation/replacement -> coronoid fixation
. Coronoid fixation -> LUCL repair -> radial head fixation/replacement

Correct Answer & Explanation

. Coronoid fixation -> radial head fixation/replacement -> LUCL repair

Explanation

The standard surgical algorithm for a terrible triad injury generally progresses from deep to superficial and from anterior to posterior if performed through a single lateral approach, though modern techniques often utilize a dual incision. The accepted structural sequence is to establish the anterior buttress first by repairing or fixing the coronoid, followed by restoring the radiocapitellar contact via radial head fixation or arthroplasty, and finally restoring lateral stability by repairing the LUCL. Medial collateral ligament repair or hinged external fixation is reserved for residual instability.

Question 3659

Topic: 9. Shoulder and Elbow

A 20-year-old rugby player presents with acute dyspnea, dysphagia, and severe pain over the medial clavicle after falling directly onto the posterolateral aspect of his shoulder. Clinical examination suggests a posterior sternoclavicular (SC) joint dislocation. What is the most appropriate imaging modality to confirm the diagnosis and assess associated injuries?

. Standard anteroposterior radiograph of the chest
. Serendipity view radiograph
. Computed tomography (CT) scan of the chest
. Magnetic resonance imaging (MRI) of the brachial plexus
. Duplex ultrasound of the subclavian vessels

Correct Answer & Explanation

. Computed tomography (CT) scan of the chest

Explanation

Posterior sternoclavicular dislocations are orthopedic emergencies due to the proximity of the great vessels, trachea, and esophagus to the medial clavicle. While a serendipity radiograph can suggest the diagnosis, a CT scan of the chest with intravenous contrast is the gold standard. It precisely delineates the bony displacement and evaluates for compression or injury to the critical retrosternal structures.

Question 3660

Topic: 9. Shoulder and Elbow
A 'floating shoulder' results from ipsilateral fractures of the clavicle and the scapular neck, causing a double disruption of the superior shoulder suspensory complex. Which of the following isolated radiographic findings represents the strongest indication for operative intervention?
. Clavicular displacement of 5 mm
. Scapular neck angulation of 20 degrees
. Glenoid medialization >10 mm and angular deformity >40 degrees
. Concomitant undisplaced coracoid fracture
. Intra-articular step-off of 1 mm

Correct Answer & Explanation

. Glenoid medialization >10 mm and angular deformity >40 degrees

Explanation

The superior shoulder suspensory complex (SSSC) is a bony/soft tissue ring. A double disruption (floating shoulder) was historically thought to be an absolute surgical indication. However, modern evidence suggests many do well with nonoperative management unless there is severe displacement. Operative fixation is strongly indicated when there is significant translation (medialization of the glenoid >10-20 mm) or severe angulation (>40 degrees) of the scapular neck, which alters the glenohumeral biomechanics and rotator cuff tension.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page